Questioning Medicine: The Pain Management Fiasco

Joe Weatherly, DO, and Andrew Buelt, DO, are family medicine residents in St. Petersburg, Fla. Together, they co-produce the podcast Questioning Medicine, where they deconstruct issues confronting today's clinicians. In this guest blog, Weatherly gives his take on the opioid abuse epidemic and how to manage patient pain without sending someone down the path of addiction.

I spent my intern year at a community hospital that was equipped with an acute detoxification center. I was exposed to addiction routinely.

There, I discovered that people, REAL everyday people, become addicts. Some of those people had a clear indication for obtaining legal pain medication. Their pain became too much for non-opiate relief in the eyes of both the patient and the physician. And, subsequently, they both plunged into the unknown of optimal pain relief coupled with potential abuse and/or addiction.

A short time later, I read a blog post about prescription opioid restrictions. And in a matter of days, 900 people in one Florida county posted comments about how much pain they had and how they were having a hard time filling their various narcotic prescriptions.

Many of the commenters wrote lengthy, passionate cries to rally together and overthrow the governor of Florida. Others simply raged in brief, as if leaving comments were part of a defeatist, low-scoring game of Words With Friends. All of them expressed disenchantment with the healthcare system, too.

This blog post and reader reaction occurred during the same week that a local supermarket decided to refuse filling prescriptions for opiate pain medications that were not written by a "pain management specialist."

After I stopped laughing, and shredded my grocery store reward card, I came up with a few questions.

How can we treat pain in America without abuse? How can we not treat pain knowing real pain exists? And yet, how can we expose naive patients to potentially habit-forming, life-altering substances as part of routine treatment?

Based off of my time working in that first clinic, and many since then, I'd like to suggest the following problems and fixes in pain management.

1. Undertreating pain. It's debilitating for the patient, even if just for a short time. It's harmful. Some individuals are left with lasting effects just from experiencing under- or untreated pain.

The Fix: For those with pain that cannot be controlled with tramadol, nonsteroidal anti-inflammatory drugs (NSAIDs), or acetaminophen, treat their pain with methadone. It's scalable with low abuse potential. It's also cost-effective at roughly $10 for a 60-tablet, 10-mg prescription. Reasonable on all accounts.

With this protocol, all other narcotic pain medications for routine prescription in America could be eliminated outside of the hospital setting. And, the pharmaceutical industry might be encouraged to develop new, noninferior/non-narcotic pain-altering medications with next level treatment. Come get the carrot, Big Pharma.

2. Setting up a person with genetic and other risk factors for potential addiction to narcotics.

The Fix: Pharmacogenomics research will spell out details as time goes forward. Until then, thorough, old-fashioned screening based on social and family history, and a discussion about risks and benefits, are good ideas. Create a relationship with your patients. Get to know them.

Help them make the best possible decision by giving unbiased, yet individualized information. Develop a pain contract. Demand attendance at psychotherapy or cognitive behavioral therapy with every month of pain medication. Work on all aspects of the pain to successfully treat all the sources.

3. A clear-cut case of abuse that isn't nipped in the bud, but rather passed on to an uninformed clinician.

The Fix: Once we have a red flag that our patient is violating the pain contract, the evidence should be turned over to the Joint Commission. They can scare anyone straight. If they are busy, perhaps a retired infection control nurse. I have a feeling there will be a mass surrender to the authorities seeking asylum in a matter of days.

Simply telling a patient, "I'm sorry, I can't give you pain medications anymore," and sending them on to the next clinician with no clear follow-through amounts to vain threats. Create a part of the healthcare community to do something other than publish physician reimbursements or perks over $10 from Big Pharma.

We need help to care for our patients and follow them through their most difficult times. By ensuring continuity of care in an ever expanding field, and delivering reliable patient information from pharmacy and prescriber to any new clinician, some of these gaps could shrink substantially.

A universal EHR! I cannot believe I just wrote that. But, once we find a good EHR, we should make it universal. It will be worth it. We can all see the potential. I think we all have high expectations for where it can go in the future, and I am not just talking sticker price and maintenance fees.

Finally, there are alternate therapies. Osteopathy and chiropractic medicine, as well as others, have their place in pain management. Let the patient be aware that while they are not for all people, or indications, they are successful for some people and many indications.

It is unlikely that alternate therapies will do what orthopedic surgery, neurology, and pain management have been unsuccessful at over the past 15 years, but they might. It's worth taking diverse approaches to complicated problems. Awareness of modalities for pain in physical therapy and massage therapy can be potent treatments with an appropriate indication.

Don't be afraid to discuss with your patients the reality that this pain might require more effort to eradicate than just swallowing a pill. Challenge them to actively participate in their own recovery. Give reasonable boundaries and expectations.

Insert other vague power words (here) that urge and inspire you to be the clinician that your mother thinks you are.

Thank you for reading. Your thoughts are welcome. We are always available on Twitter @MedQuestioning and @AndrewBuelt. Feel free to come up with Harms and Fixes of your own and post in the comments section.

Accessibility Statement

At MedPage Today, we are committed to ensuring that individuals with disabilities can access all of the content offered by MedPage Today through our website and other properties. If you are having trouble accessing www.medpagetoday.com, MedPageToday's mobile apps, please email legal@ziffdavis.com for assistance. Please put "ADA Inquiry" in the subject line of your email.